Permission to Release Films and Records

Please correct the errors described below.

Directly to the office of my new provider,

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Please note: We follow the accepted Maine Dental Association policy for the release of records. It states, in part:

  1. Originals are kept in the treating dentist's file. Treatment records, including radiographs, should be duplicated and only the duplicates released.
  2. All requests for records should be in writing from the patient or guardian.
  3. Copies of records may not be withheld because of an outstanding bill with the dental office.
  4. A fee may be charged for duplicating and mailing.
  5. Copies must be released by an authorized representative within a reasonable time.

A copy of the Maine law can be obtained from the MDA Central Office of it may be accessed from the State of Maine website:

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